In-depth interviews were performed with n = 23 respondents (see Table 2): five interviews were duo interviews, and one interview took place with n = 3 respondents representing one organization. We had n = 6 refusals: n = 3 because of time restraints, n = 1 did not feel sufficiently knowledgeable about the topic, n = 1 changed professional function, and there was n = 1 nonresponse. Respondents had various ways in which they related towards the macro-context: we included actors that formed part of external context (e.g., the Flemish Agency of Care and Health), actors that facilitate and strengthen organizations in the implementation of GOC (e.g., the umbrella organization for community health centers), and actors that actively convey GOC inside and outside their setting (e.g., an autonomous and integral home care service). Interviews lasted between 47 and 72 min. Table 3 gives an overview on the main findings of our deductive analysis with their respective links to the propositions of each of the organizational theories that we applied as a lens.

Table 2 Overview of respondents and type of organizationTable 3 Overview of organizational theory and applications to the implementation of GOCInstitutional theory: laying foundations for a shift towards GOC

For the implementation of GOC in primary care, looking at the data with an institutional theory lens helps us understand the way in which primary care organizations will respond to social structures surrounding them. Institutional theory describes the influence of institutions, which give shape to organizational fields: “organizations that, in the aggregate, constitute a recognized area of institutional life [31], p. 148. Prevailing institutions within primary care in Flanders can affect how organizations within such organizational fields fulfil their activities. Throughout our interviews, we recognized several dynamics that are being described in institutional theory.

First of all, the changing landscape of primary care in Flanders (see 1.2) was often brought up as a dynamic in which GOC is intertwined with other changes. Respondents mention an overall tendency to reform primary care to becoming more integrated and the ideas of person-centered care becoming more upfront. These expectations in how primary care should be approached seem to affect the organizational field of primary care: “You could tell that in people’s minds they are ready to look into what it actually means to put the patient, the person central. — INT01” Various policy actors are committed to further steer towards these approaches: “the government has called it the direction that we all have to move towards. — INT23” It was part of the foundations for the most recent primary care reform, leading to the creation of demographic primary care zones governed by care councils and the Flemish Institute of Primary Care as supporting institution.

These newly established actors were viewed by our respondents as catalysts of GOC. They pushed towards the aims to depart from local settings and to establish connections between local actors. Overall, respondents emphasized their added value as they are close to the field and they truly connect primary care actors. “They [care councils] have picked up these concepts and have started working on it. At the moment they are truly the incubators and ecosystems, as they would call it in management slang. — INT04” For an innovation such as GOC to be diffused, they are viewed as the ideal actors who can function as a facilitator or conduit. They are uniquely positioned as they are closely in contact with the practice field and can be a top-down conduit for governmental actors but also are able to address the needs from bottom-up. “In this respect, people look at the primary care zones as the ideal partners. […] We can start bringing people together and have that helicopter view: what is it that truly connects you? — INT23” However, some respondents also mentioned their difficult governance structure due to representation of many disciplines and organizations.

Other regulatory factors were mentioned by respondents were other innovations or changes in primary care that were intentionally linked to GOC: e.g., the BelRAIFootnote 2 or Flemish Social ProtectionFootnote 3. “The government also provides incentives. For example, family care services will gradually be obliged to work with the BelRAI screener. This way, you actually force them to start taking up GOC. — INT23” For GOC to be embedded in primary care, links with other regulatory requirements can steer PCPs towards GOC. Furthermore, it was sometimes mentioned that an important step would be for the policy level to acknowledge GOC as quality of care and to include the concept in quality standards. This would further formalize and enforce the institutional expectation to go towards person-centered care.

Currently, a challenge on institutional level as viewed by most respondents is that GOC is not or only to a limited extent incorporated in the basic education of most primary care disciplines. This leads to most of PCPs only having a limited understanding of GOC and different disciplines not having a shared language in this matter. “You have these primary health and welfare actors who each have their own approach, history and culture. To bring them together and to align them is challenging. — INT10” The absence of GOC as a topic in basic education is mentioned by various respondents as a current shortcoming in effectively implementing GOC in the wider primary care landscape.

Overall, GOC is viewed as our respondents as a topic that has recently gained a lot interest, both by individual PCPS, organizations, and governmental actors. The Flemish government has laid some foundations to facilitate this change with newly created institutions and incentives. However, other external context variables can interfere in how the concept of GOC is currently being picked up and what challenges arise.

Resource dependency theory: in search for a financial system that accommodates interprofessional collaboration

Another external context variable that affects how GOC can be introduced is the financial system that is at place. To analyze themes that were raised during the interviews with regard to finances, we utilized a resource dependency perspective. This theory presumes that organizations are dependent on financial resources and are seeking ways to ensure their continued functioning [16, 17]. To a certain extent, this collides with the assumptions of institutional theory that foregrounds organization’s conformity to institutional pressures [32]. Resource dependency theory in contrast highlights differentiation of organizations that seek out competitive advantages [32].

In this context, respondents mention that their interest and willingness to move towards a GOC approach are held back by the current dominant system of pay for performance in the healthcare system. This financial system is experienced as restrictive, as it does not provide any incentive to PCPs for interprofessional collaboration, which is key for GOC. A switch to a flat fee system (in which a fixed fee is charged for each patient) or bundled payment was often mentioned as desirable. PCPs and health/social care organizations working in a context where they are financially rewarded for a trajectory or treatment of a patient in its entirety ensure that there is no tension with their necessity to obtain financial resources, as described in the resource dependency theory. Many of our respondents voice that community health centers are a good example. They cover different healthcare disciplines and operate with a fixed price per enrolled patient, regardless of the number of services for that patient. This promotes setting up preventive and health-promoting actions, which confirms our finding on the relevance of dedicated funding.

At the governmental level, the best way to finance and give incentives is said to be a point of discussion: “For years, we have been arguing about how to finance. Are we going to fund counsel coordination? Or counsel organization? Or care coordination? — INT04” Macro-level respondents do however mention financial incentives that are already in place to stimulate interprofessional collaboration: fees for multidisciplinary consultation being the most prominent. Other examples were given in which certain requirements were set for funding (e.g., ImpulseoFootnote 4, VIPAFootnote 5) that stimulate actors or settings in taking steps towards more interprofessional collaboration.

Nowadays, financial incentives to support organizations to engage in GOC tend to be project grants. However, a structural way to finance GOC approaches is currently lacking, according to our respondents. As a consequence, a long-term perspective for organizations is lacking; there is no stable financing and organizations are obliged to focus on projects instead of normalizing GOC in routine practice. According to a resource dependency perspective, the absence of financial incentives for practicing GOC hinders organizations in engaging with the approach, as they are focused on seeking out resources in order to fulfil their core activities.

A network-theory perspective: the importance of connectedness for the diffusion of an innovation

Throughout the interviews, interorganizational contextual elements were often addressed. A network theory lens states that collaborating in networks can lead to outcomes that could not be realized by individual organizations acting independently [19, 20]. Networks consist of a set of actors such as PCPs or health/social care organizations along with a set of ties that link them [33]. These ties can be state-type ties (e.g., role based, cognitive) or event-type ties (e.g., through interactions, transactions). Both type of ties can enable a flow in which information or innovations can pass, as actors interact [33]. To analyze the implementation process of GOC and how this is diffused through various actors, a network theory perspective can help understand the importance of the connection between actors.

A first observation throughout the interviews in which we notice the importance of networks was in the mentioning of local initiatives that already existed before the creation of the primary care zones/care councils. In the area around Ghent, local multidisciplinary networks already organized community meetings, bringing together different PCPs on overarching topics relating to long-term care for patients with chronic conditions. These regions have a tradition of collaboration and connectedness of PCPs, which respondents mention to be highly valuable: “This ensures that we are more decisive, speaking from one voice with regards to what we want to stand for. — INT23” Respondents voice that the existence of such local networks has had a positive effect on the diffusion of ideas such as GOC, as trust between different actors was already established.

Further mentioning of the importance of networks could be found in respondents acknowledging one of the presumptions of network theory: working collaboratively towards a specific objective leads to outcomes that cannot be realized independently. This is especially true for GOC, an approach that in essence requires different disciplines to work together: “When only one GP, nurse or social worker starts working on it, it makes no sense. Everyone who is involved with that person needs to be on board. Actually, you need to finetune teams surrounding a person — INT11.” This is why several policy-level respondents mentioned that emphasis was placed on organizing GOC initiatives in a neighborhood-oriented way, in which accessible, inclusive care is aimed at by strengthening social cohesion. This way, different types of PCPs got to know each other through these sessions an GOC and would start to get aligned on what it means to provide GOC. However, in particular, self-employed PCPs are hard to reach. According to our respondents, occupational groups and care councils are suitable actors to engage these self-employed PCPs, but they are not always much involved in such a network.

To better connect PCPs and health/social care organizations, the absence of connectedness through the technological landscape is also mentioned. Current technological systems and platforms for documenting patient information do not allow for aligning and sharing between disciplines. In Flanders, there is a history of each discipline developing its own software, which lacks centralization or unification: “For years, they have decided to just leave it to the market, in such a way that you ended up with a proliferation of software, each discipline having its own package. — INT06” Most of the respondents mentioning this were aware that Flanders government is currently working on a unified digital care and support platform and were optimistic about its development.

Contingency theory: how environmental pressure can be a trigger for change

Our interviews were conducted during a rather dynamic and unique period of time in which the impact of social change and pressure was clearly visible: the Flemish primary care reform was ongoing which leads to the creation of care councils and VIVEL (see 3.1.1), and the COVID crisis impacted the functioning of these and other primary care actors. These observed effects of societal changes are reminiscent of the assumptions that are made in contingency theory. In essence, contingency theory presupposes that “organizational effectiveness results from fitting characteristics of the organization, such as its structure, to contingencies that reflect the situation of the organization [34], p. 1.” When it comes to the effects of the primary care reform and the COVID crisis, there were several mentions on how primary care actors reorganized their activities to adapt to these circumstances. Representatives of care councils/primary care zones whom we interviewed underlined that they were just at the point where they could again engage with their original action plans, not having to take up so many COVID-related tasks anymore. On the one hand, the COVID crisis had however forced them to immediately become functional and has also contributed that various primary care actors quickly got to know them. On the other hand, the COVID crisis has also kept them from their core activities for a while. On top of that, the crisis has also triggered a change the overall view towards data sharing. Some respondents mention a rather protectionist approach towards data sharing, while data sharing has become more normalized during the COVID crisis. This discussion was also relevant for the creation of a unified shared patient record in terms of documenting and sharing patient goals.

Other societal factors that were mentioned having an impact on the uptake of GOC are the demographic composition of a certain area. It was suggested that areas that are characterized by a patient population with more chronic care needs will be more likely to steer towards GOC as a way of coping with these complex cases. “You always have these GPs who blow it away immediately and question whether this is truly necessary. They will only become receptive to this when they experience needs for which GOC can be a solution — INT11.” On a macro-level, several respondents have mentioned how a driver for change is to have the necessity for change becoming very tangible. As PCPs are confronted with increasing numbers of patients with complex, chronic needs and their work becomes more demanding, the need for change becomes more acute. This finding is in line with what contingency theory underlines: changes in contingency (e.g., the population that is increasingly characterized by aging and multimorbidity) are an impetus for change for health/social care organizations to resolve this by adopting a structure that better fits the current environmental characteristics [34].